Bad News Bear.

There’s an aspect of being a doctor that never gets easy and that is delivering bad news.

In medical school we take a course called “Breaking Bad News“, but nothing prepares you for actually having to do it.

I’ve had my family practice for 7 years and have been practicing medicine for almost 10. I can still remember every single time I’ve had to give bad news.

  • While working at a walk-in clinic, over the Christmas holidays, I had to tell a woman she had pancreatic cancer.
  • In my first year of family practice, I told a woman she had cervical cancer.
  • In my second year of family practice, I felt a pancreatic mass in a 55-year-old woman; she lived for 4 years after that. I attended her funeral.
  • Three years ago, I felt a very abnormal prostate gland and new instantly the patient had prostate cancer.
  • A young woman, believed to be about 3 months pregnant came in for an unrelated matter and asked if we could listen to the heartbeat. She’d seen her midwife the previous week and they couldn’t find it.  Neither could I.  An ultrasound a few hours later confirmed what I already knew.  She’d suffered a miscarriage but didn’t know it.
  • There was an older woman who came to see me for chest pain. She had been coughing from a cold and had a lot of chest wall pain. An x-ray showed multiple rib fractures. Spontaneous rib fractures.  A week later, after sending her for a series of blood tests, I diagnosed Mulitple Myeloma.
  • Sometimes a diagnosis of chlamydia can be devastating.  It certainly was in the 31-year-old married woman who came in for a routine Pap.  Sadly, my bad news was instrumental in her later ending her marriage.
  • My first week back to work, I told a man he most likely had kidney cancer.  Welcome back!

Every time I have to deliver bad news I am reminded how fortunate I am and how fortunate my patients are for living in a country where, when its required, they have access to timely health care.  None of the above patients waited for more than a week or two to see a specialist.  Sadly, not everyone survives after being given bad news. I haven’t had to do it very often, but when I do, it affects me personally.  Often I can’t sleep for a few days.  Sometimes I worry (often unnecessarily) that I missed the boat and should have caught the illness at an earlier stage.  Anything else going on in my life suddenly seems not to matter for a while.

Bad news bear.

Sometimes that’s me.

 

 

Cancer Blows.

Prior to my maternity leave, one of my patients had been diagnosed with pancreatic cancer.  She was set up with specialists, I reassured both her and her husband that they were in excellent hands with my locum and promised to be in touch with them as soon as I could.  My locum has been keeping me up to date on this particular patient as well as a few others.  This patient had major surgery a few weeks ago to remove the tumor and reportedly has been doing well.  I read the operative report today.  She had a procedure known as the Whipple.

The Whipple is a complicated procedure.  I saw one performed once as a medical student and all I remember is holding a retractor for a very, very long time.  Generally speaking, pancreatic cancer is not a good cancer to be diagnosed with – I mean, no cancer is, but this one in particular can kill a patient very quickly if it’s not caught early.  Thankfully, I believe my patient’s tumor was found early and according to the operative report, the Whipple procedure was considered curative.  Curative!! If I believed in God and Angels, I would say she definitely has an Angel looking after her.

Cancer is one of those illnesses that, I believe, touches all of us in one way or another.  My mother had breast cancer, diagnosed 12 years ago while I was still in medical school.  My mom was one of those women who always did self-breast examinations because she was prone to developing cysts.  I remember when I was a lot younger, she went in for day surgery to have a lump removed.  It was benign, but ever since then I always remember her feeling her breasts, always checking for something.  Well, on one of those checks, she felt something different.  Her family doctor couldn’t feel it; the radiologist couldn’t feel it; the breast surgeon couldn’t feel it.  But my mom did and the mammogram proved it. She had a lumpectomy about a month later and it was proven to be contained within the breast with no evidence of spread to the lymph nodes.  She had 5 weeks of radiation therapy, took Tamoxifen for five years and is considered cured.  Her having breast cancer does not necessarily increase my risk as she was post-menopausal at the time of diagnosis, but I still plan on being vigilant and likely will get my first mammogram next year when I turn 40.

Husband’s father was diagnosed with bladder cancer at the age of 62. Like most individuals diagnosed with bladder cancer, he presented to his doctor with gross hematuria (frank blood in the urine).  His tumor was small, localized and initially treated with an immune-stimulating drug called BCG (made of the bacteria that causes Tuberculosis).  It seemed to work at first but several months, maybe a year later, he developed acute renal failure and it was discovered that the tumor had spread outside the bladder wall and was blocking one of the ureters that drains the kidney.  I believe he underwent chemotherapy at that time, as surgery was no longer an option due to local spread.  Sadly, he died about a year and a half after the initial diagnosis. His risk factors were his age (>40) and his sex (male).  He never smoked, but he did work in the pharmaceutical industry as a pharmacist for many years back in Scotland, so it’s possible he was exposed to some chemicals back then.  We’ll never know.   As husband has just turned 40, I remind him periodically that he needs to go for his check up.

I remember a particularly difficult case I worked on during my family medicine training.  I spent two months on the Palliative Care unit. Palliative care is end of life care. More than that, it is medical care and treatment during the process of death and dying, not only for the patient, but for the family as well.  Difficult under any circumstances, but brutally awful in this particular case,which was a 44-year-old mother of two children, dying of colon cancer.

Colon cancer is one of those illnesses you think happens to a man in his sixties.  At least it was for me, as a medical student and resident.  But those two months on the Palliative care ward taught me otherwise.  Almost 10 years later, I don’t remember the details of the case, but what I do remember is that cancer can strike anyone, at any age.  My job as a family physician is to be suspicious and cognizant of that fact.  Anyone with symptoms of anemia, weight loss, change in bowel habit, vague abdominal pain/cramping, night sweats, regardless of their age – these are all red flags that need to be paid attention to.  Sadly for this woman, her physician lacked a certain amount of imagination and her tumor wasn’t discovered until it was too late.

I recently visited the RateMyMD website and looked myself up.  I was pleasantly surprised to see several new comments, and yes, they were all positive. (Giving myself a pat on the back right now!)  One in particular stood out.  This patient was new to my practice, having seen her husband’s physician for many years.  This physician was retiring and she sought out a younger, female doctor.  She got me. Apparently, at her first annual physical exam with me, I asked her about colorectal cancer screening.  She had never had a colonoscopy – it was never brought up by her previous doctor.  She had the “home testing kit” done every few years.  These fecal occult blood tests (FOBT) are designed to detect microscopic blood – blood not visible to the naked eye.  The thing is, not all tumors bleed, so the test might miss one.  Colonoscopy is the gold standard test for detecting colon cancer.  Guidelines for screening state that all patients > 50 years of age should have one every ten years.  However, this usually doesn’t happen because of wait times and cost to the healthcare system. Thus, the FOBT became a test to do in between colonoscopy.  Despite the guidelines, most physician will still recommend for all of their patients to have at least one colonoscopy.  Apparently, I talked about it enough at this woman’s appointment that she agreed to have one.  Turns out, I saved her life.  She had several precancerous polyps which were removed during her colonoscopy.

It’s a no-brainer, folks.  Screening tests work, be it mammography for breast cancer or Pap smears for cervical cancer.  If anyone reading this has a family history of cancer, or is of the age that a screening test is recommended, please get your screening done.  It really might just save your life.